Doctors mistrust systems for reporting medical mistakes

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In today's BMJ we have reports that begin to explain why it has been
so easy to accuse parents of harming their child; this one and the paper
on adverse drug reactions. [1]

The following is a true account of what can happen.

A baby is admitted to hospital because it stops breathing, baby is
diagnosed as having GERD, baby is prescribed a medication for which there
are known adverse events leading to black box warnings. Baby is
discharged.

Weeks later baby is readmitted having had an apparent life
threatening event, nothing can be found, baby undergoes and ECG which
shows that baby is borderline Long QT, child is not taken off the
prescribed medication even though it is contraindicated with heart
conditions, baby is discharged home.

Days later baby again readmitted with an ALTE, doctors become
suspicious and think mother may have caused baby's problems, however after
careful observation on the ward, decide no evidence and discharge baby and
mother.

Days later the child is admitted again, this time no ALTE but other
symptoms listed as being an adverse reaction to drug given for GERD.
Prescribed medication not given for hours as hospital are too busy trying
to lower Inter Cranial Pressure, baby stabilises and parents told to go
home because baby is heavily sedated and there are no beds.

Baby given prescribed medication and immediately deteriorates, other
drugs contraindicated with prescribed drug and Long QT syndrome
administered whilst attempting to save baby's life. Baby dies but is kept
on life support machine until parents arrive.

Nobody reported the adverse drug reaction, everyone kept quiet about
the mistakes that were made in the attempts to save this baby, nobody ever
thought to look at the drug (which is now banned) as the cause of the
baby's problems. Instead they blamed the mother and accused her of MSbP.

They were able to do that because nothing in the records showed what
had really happened because everyone was to afraid to report it and
therefore the mother had "no proof" that it was nothing she had done.

All the parents ever wanted was an apology and assurances that
something like this could never happen again, what they got instead was a
living nightmare.

We finally have the proof of what happened that night, it's taken
years of investigation. The mother's case has been marked for urgent
review under the direction of M Hodge MP, too little too late. The damage
done to this family is incalculable.

Perhaps with these two reports in the BMJ others might not be so
quick to jump the gun and assume a parent harmed a child before proper
investigations into ALL aspects of care a child receives.

Next time a medic or nurse are too scared to report an incident
because of the implications to them, perhaps they would like to think
twice, this may be an extreme example of what can happen, however it did
happen and it has destroyed countless other lives as a result.

Stop practising defensive medicine and start telling the truth, you'd
be surprised how many of "us" would settle for that.

Sadly because the medics involved followed the course of action
described, inevitably they will probably lose their jobs and possibly
their freedom.

[1]BMJ 2004;329:15-19 (3 July), doi:10.1136/bmj.329.7456.15

I have read out an obtained permission to relay this account from the
parents.

Competing interests:
Campaigner against false allegations of MSbP. Advocate for the family in the case study quoted in this response.